Chronic Shoulder Pain! Why does it not get better? – A Case Report
Brock, a 31 year old investment banker, presented to Castlemore Advance Therapeutics with 6 months of shoulder pain. His symptoms were manageable at first but eventually began affecting his daily activities. He was no longer able to train his upper body at the gym and recently he reported having difficulty performing simple tasks such as opening doors. I could really sense Brock’s frustration. He reported seeing multiple therapists including a physiotherapist, massage therapist, family doctor and another chiropractor. All therapists had the same diagnosis. Biceps tendonitis! There was even an ultrasound confirming that this was exactly the problem. But was it?
The shoulder is a very complex section of the body. There are 4 joints involved when moving your shoulder. When all joints are in there optimal position, the muscles work efficiently and pain does not occur. However, this is rarely the case. We often do the same activities daily, weather it is work, or play. Our bodies are able to adapt very well. For this reason we are able to tolerated movement inefficiencies for a long time before we notice any pain or discomfort. When the symptoms do occur, it is often in a structure that can compensate the least. It doesn’t mean that it is the problem.
A common example I see at Castlemore Advanced Therapeutics is a patient with rotator cuff or biceps tendon issues from sitting at a desk all day. When an individual works in a seated position, their knees, hips, back, shoulders, elbows, and wrists are flexed. Working 8 plus hours a day in this position will really develop all the flexing muscles of the body. As a result, all the opposite muscles are being stretched, slowly getting weaker and creating an imbalance. The body can only do this for so long before pain or injuries start to happen. This is exactly what happened to Brock. To make matters worse, his exercise regimen was significantly weighted toward training the front of his body. The flexors! This only pushed him further into imbalance.
When observing Brock’s posture, I noticed his shoulders were rounded in the front, his head was slightly forward, his shoulder blades were hiked and his arms were rotated inwards. With his body in this position, it was clear that his biceps tendon was taking a beating. The biceps muscle has 2 different attachments sites. One is at the top of the ball and socket joint and the other is at the front of the shoulder blade right under the pectoral muscle. When the shoulder is in a rotated and hiked position, it closes the space in which the biceps runs and creates friction of the tendon with bone and other structures. This results in chronic swelling around the biceps tendon and sheath leading to biceps tendonitis.
All the muscle and orthopaedic tests confirmed the diagnosis of biceps tendonitis. This was not surprising as the ultrasound indicated there was a problem there. I kept looking and found weakness in the lower trapezius muscle (mid back) and a complete inability to engage the latissimus muscle (big back muscle that covers most of the back). Moreover, testing of the pectoralis major and minor muscle was really strong but also very tender to touch. He described the pain like muscle soreness post exercise. This makes a lot of sense since those muscles have been working overtime.
It was clear all the treatments in the world on the biceps tendon will not make his tendonitis go away unless his shoulder position was corrected. For 2 weeks I focused my treatment including Active Release Techniques, Graston therapy and joint mobilization on the structures that hike the shoulder, brought the shoulder forward and turn the arm inwards. This encouraged lengthening of the shortened muscles and allowing the shoulder to return in the correct position. Strengthening exercises to stimulate the weak muscle of the back were also performed during each treatment session to pull the shoulder in the proper direction.
Brock was also given homework to stretch the muscles of the chest and top of the shoulder 3 times per day holding for a minimum of 30 seconds as well as continue to strengthen the weak muscle of the back (latissimus dorsi and lower trapezius).
After 2 weeks Brock noticed less difficulty performing his daily activities but still had some discomfort lifting weights. At this point we decreased his treatment frequency to once a week but encouraged him to seek professional advice from a qualified personal trainer. The personal trainer designed a more balance exercise regimen helping Brock strengthen his back muscle and restoring his shoulder in the right position.
Shortly after, Brock presented to the clinic pain free. He reported being able to perform all the exercises he did prior to his shoulder injury and noticed significant gains in all of his exercises.
It is easy to be focused on the area of pain as a patient and a therapist. Especially when there is imaging confirming an injury. Brock’s case is a perfect example to evaluate the body as a whole. The body will always find a way to perform a task and will often choose the path of least resistance to accomplish it. His biceps tendon could not continue to compensate for the weakness in his back muscles and overworked chest muscles. It wasn’t the problem. It was the victim.
